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VIII. Appendix A - Acknowledgement/Receipt Form <br />acknowledge, by signinq this form, that my full compliance with the Anti -Drug and Alcohol Misuse <br />Prevention Plan (the "Plan") and DOT drug and alcohol regulation requirements is a condition of my <br />initial and continued employment with the Company. I understand and agree that I may be discharged <br />or otherwise disciplined for any drug and/or alcohol violation committed by me as cited in the Plan and/or <br />in the DOT drug and alcohol regulatory requirements. <br />I also acknowledge, by sianina this form, that a copy of the Plan has been made available to me and that <br />misuse. <br />Signed,thisthe day of , 20 <br />Employee Name (Please Print) <br />Employee Signature <br />Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 38 <br />QJ NATIONAL COMPLIANC[ M�MACEMENT SERVICE, I�IG. (�ICMS) 20� 1 (updzle �02tJ. The IVCMS plan is <br />tl�s subjeG of a reyisteretl copyriyM1� and is pro�Od¢d by copyrghl laws rn the U.S. and else�vliera. All riglils <br />escrvad. <br />